Transcript Document

Practical Food Allergy Management
Education for Your Patients
Michael Pistiner MD, MMSc
Pediatric Allergist, Harvard Vanguard Medical Associates
Management of IgE Mediated
Food Allergy
• Written action plan with provision of 2 doses of epinephrine
(NIAID 6.4)
• Patient/Family Education
• Consideration for emergency identification jewelry (NIAID
6.4.2.1)
• Monitor nutritional and growth status and provide nutritional
counselling (NIAID 5.1.4)
Epinephrine
• First-line treatment for anaphylaxis.
• Delays in administration associated with
increased mortality
(Simons. JACI 109: 171-175, 2002),(NIAID 6.3.1.1.)
Epinephrine: Frequency
• If symptoms progress or poor response then repeat
dosing after 5 to 15 minutes
• 10% to 20% may require greater than one dose
(Jarvinen et. al. J Allergy Clin Immunol. 2008 Jul; 122:133–138)
(Oren et. al, Ann Allergy Asthma Immunol. 2007 Nov; 99: 429–432)
NIAID 6.3.1.1
Epinephrine: Dosing
• Recommended dosing is 0.01mg/kg up to
0.5mg IM (DO NOT PUSH IV)
– 1:1000 epinephrine (1mg/ml)
• Auto-injectors: Two available doses
– 0.3mg
– 0.15mg
– Upsize to 0.3mg for >=25kg (55lb)
Sicherer and Simons. Pediatrics. 2007 Mar;119(3):638-46, NIAID 6.3.1.1.
Anaphylaxis Practice Parameters. JACI.2005
Muraro A. Et Al. Mgmt. Anaph childhood. Allergy 2007
Sampson et al. JACI 2006;117:391-7
Epinephrine:
Prescriptions
• Specific Child
– Enough to ensure that 2
doses are available in all
situations
• Non-specific/Stock
Epinephrine
– Standing orders for school for
availability of 2 doses of
0.15mg and 0.3mg dosing
NIAID 6.4.2.2
Sig:
Epinephrine Auto-injectors
0.15mg
Administer IM in anterolateral thigh for severe
allergic reaction and call 911
Dis:
2 Two Packs
One for home and one for
school
Epinephrine:
Available Auto-injectors
Adrenaclick® &
Generic Epinephrine
Auvi-Q®
EpiPen®
Currently 4 auto-injectors available in US
(As of November 2014)
Online video training available
Epinephrine:
Availability and Storage
• Readily available at ALL times
(unlocked)
• Avoid Extreme temperatures
– Keep at 15-30°C (59-86°F)
– Do not store in car
• Monitor auto-injector
expiration dates (NIAID 6.4.2.3.)
EXP MAY 15
Epinephrine:
Common & Expected Side Effects
•
•
•
•
•
•
Pallor (100%)
Tremor (80%)
Anxiety (70%)
Tachycardia (50%)
Headache (20%)
Nausea (20%)
(Simons. JACI 109: 171-175, 2002)
Epinephrine:
Contraindications/Considerations
• No contraindication if treatment for anaphylaxis
• Caution with cardiac issues, arrhythmias,
uncontrolled hypertension or hyperthyroidism, aortic
aneurysm, recent intracranial surgery and patients on
sympathomimetics, TCAs, MAO inhibitors
• Beta blockers decrease
response to epinephrine
(NIAID 6.3.3)
(Anaphylaxis Practice Parameters. JACI.2005)
(Sicherer and Simons. Pediatrics. 2007; 119;638-646)
Epinephrine:
Considerations with asthma
• If ever any concern that a food allergic reaction has
triggered an asthma attack then treat with
epinephrine first
• Delays in epinephrine use are associated with
increased risk of death
Antihistamines
“The use of antihistamines is the most
common reason reported for not using
epinephrine and may place a patient at
significantly increased risk for progression
toward a life-threatening reaction.”
–NIAID 6.3.1.
(Simons et. al. J Allergy Clin Immunol. 2009 Aug; 124: 301–306)
Antihistamines
• Antihistamines are not first line treatment of
anaphylaxis and do not stop or prevent it
• Slow to act (30-60 minutes)
• Non-licensed responders may not be able to give
antihistamines in some states and schools
(Young. Pediatric Allergy: Principles and Practice 643-653. 2003)
(Sampson et al. JACI 2006;117:391-7)
(Muraro A. Et Al. Mgmt. Anaph childhood. Allergy 2007)
Food Allergy Management Education:
Challenges
• Limited education time
– Not enough time to become competent or confident in food allergy
management
– Large Volume of Information
– Significant Lifestyle Changes
– Train the trainer
• Studies of parental knowledge demonstrate
clear deficits in
– Competency in epinephrine administration (Arkwright, et al. Pediatric
Allergy Immunology 2006;17(3):227-9) (Pouessel, et al. Pediatric Allergy
Immunology 2006; 17(3):221-6)
– Allergen avoidance (Joshi, et al. JACI. 2002;109(6):1019-21)
– Information provision (Hu, et al. Arch Dis Child 2007;92:771-5)
• Misperceptions and assumptions
– Skin test size, level of IgE, air borne exposure, skin contact, danger of
epinephrine, etc.
Emotional and Social Impact of Food
Allergy
•
Fear of adverse events and death
•
Fear of ridicule
•
Social isolation
•
Limitations in activities
•
Food Allergy Related Bullying
(NIAID 5.1.10.2)
(Bollinger et al. Ann Allergy Asthma Immunol. 2006;96(3):415-21)
(Marklund et al. Health and Quality of Life Outcomes 2006, 4:48)
(Avery et. al. Pediatr Allergy Immunol 2003; 14:378-382)
(Lieberman et. al. 2010 Oct;105(4):282-6)
Food Allergy Management:
A Difficult Balance
Risk Taking
Anxiety
Allergic reactions can be prevented and dealt with
reasonably while maintaining quality of life
(NIAID 5.1.10.1)
Teach Food Allergy Basics
Definition
Specific Food Allergens
Symptoms
(Munoz-Furlong et al. Nutrition Guide To Food Allergies. FAAN. 2005)
(Sampson, HA, Hospital Practice, 2000)
(Food Allergy Practice Parameter. Annals of Allergy, Asthma & Immunology. 2006)
(Mass Dept of Education. Managing Life Threatening Food Allergies in Schools.2002)
Teach Food Allergy Basics
Timing
Anaphylaxis
Epinephrine
(Munoz-Furlong et al. Nutrition Guide To Food Allergies. FAAN. 2005)
(Sampson, HA, Hospital Practice, 2000)
(Food Allergy Practice Parameter. Annals of Allergy, Asthma & Immunology. 2006)
Food Allergy Fatal and Near Fatal
Anaphylaxis
•
•
•
•
•
Most away from the home
Unintentional ingestion with known food allergy
Majority are peanut & tree nut
Asthma is a significant risk factor
Adolescents and young adults are at greatest risk
- 70% of mortalities between ages 12 and 21
• Delayed or lack of administration of epinephrine
– 88% of fatalities
(Bock JACI 2001;107:191)
(Bock JACI 2007;119:4:1016-18)
(Sampson et al. JACI 2006;117:391-7)
(CDC, Voluntary Guidelines for Managing Food Allergies. 2013)
Pillars of Food Allergy Management
Prevention
Emergency
Preparedness
These must be applied at all times and in all settings
Routes of Food Allergen Exposure
Oral
Inhalation
Daveynin:flickr
Oddharmonic:flickr
Skin Contact
Avoid Oral Exposure
• Each label on food should be read every time
• Understand labeling laws (FALCPA) and their
limitations
• Avoid items with advisory statements (some
exceptions)
• Be familiar with hidden ingredients
NIAID 5.1.5.
Hefle et al. JACI 2007
Munoz-Furlong et al. Nutrition Guide To Food Allergies. FAAN. 2005
Avoid Oral Exposure
• Each label on food should be read every time
• Understand labeling laws (FALCPA) and their
limitations
• Avoid items with advisory statements (some
exceptions)
• Be familiar with hidden ingredients
NIAID 5.1.5.
Hefle et al. JACI 2007
Munoz-Furlong et al. Nutrition Guide To Food Allergies. FAAN. 2005
Skin Contact
• Isolated skin contact on intact skin did not cause severe or
systemic reactions in two studies, although milder reactions
occurred
• Skin contact can easily turn into an oral or mucosal exposure
especially in young children
• Systemic reactions have been reported in cases of topical
application of allergen on eczematous skin
(Simonte. JACI 2003. V112. N1. 180-2)
(Wainstein. Pediatric Allergy Immunology 2007; 18:231-9)
(Tulve et al. Journal of Exposure Analysis and Environmental Epidemiology (2002) 12, 259–264)
(Bahna. Allergy 2004: 59 (Suppl. 78): 66–70)
Inhalation
• Smells are caused by VOCs, not proteins
• No systemic reactions in small study of peanut
allergic patients with peanut butter held 1 foot
from nose
• Reactions of inhalation of fish, egg, legumes,
buckwheat, milk, and others, associated with
active cooking
• Caution with powders, flours, small particles of
food, etc.
(Roberts Allergy. 2002)
(Simonte, et al, JACI 1999)
Cross-contact
• Allergens can be transferred by objects, saliva, and food
• Exposure to small amounts of allergen is enough to cause
a serious allergic reaction
• Allergens withstand heating and drying
• Routine training for all caregivers about sources of crosscontact and prevention of exposure is essential
• Saliva and pets can be a source of cross contact
• Be aware of the developmental level and capabilities of
the child
• Different issues with different age groups
(Maloney. JACI. 2006)
(Munoz-Furlong. Pediatrics 2003)
Cross-contact
• Exposure to small amounts of allergen is enough to cause
a serious allergic reaction
• Allergens withstand heating and drying
• Routine training for all caregivers about sources of crosscontact and prevention of exposure is essential
• Saliva and pets can be a source of cross contact
• Be aware of the developmental level and capabilities of
the child
• Different issues with different age groups
(Maloney. JACI. 2006)
(Munoz-Furlong. Pediatrics 2003)
Cleaning to Prevent Cross-Contact
• Establish a cleaning protocol to avoid cross-contact
What Works: Soap and water,
commercial hand wipes
What Doesn’t: Hand sanitizers
(JACI 2004-Perry et al)
What Works: Soap and water,
commercial cleaners,
commercial wipes
Prevention Take Home Points
Read Labels
Prevent Cross-contact
Avoid Hidden Ingredients
Pillars of Food Allergy Management
Prevention
Emergency
Preparedness
These must be applied at all times and in all settings
ANAPHYLAXIS
“a serious allergic reaction that is rapid
in onset and may cause death”
NIAID 6.1
Food Allergy and Anaphylaxis
Emergency Care Plan
• Simplified criteria to identify
potential allergic emergencies for
use by patients, families,
caregivers and school staff
• Accessible and understandable
• Strongly encourage submission
to school/daycare
• Train families to use ECPs when
they train others
www.AAAAI.org
www.foodallergy.org
NIAID 6.4.2.1.
Food Allergy and Anaphylaxis
Emergency Care Plan
• Simplified criteria to identify
potential allergic emergencies for
use by patients, families,
caregivers and school staff
• Accessible and understandable
• Strongly encourage submission
to school/daycare
• Train families to use ECPs when
they train others
www.AAAAI.org
www.foodallergy.org
NIAID 6.4.2.1.
Clearly Convey the Critical Role
of Epinephrine
• First-line, treatment of choice
• Acts where we need it to
• Will make you feel better
• Fast acting
• Delays in administration increase
risk of death
• Err on the side of caution and give
if any doubt
• Safe medicine
(Sampson, JACI,134; 5; 1016–1025)
NIAID 6.3.1.1.
Auto-injector Trainers
• Anyone responsible for caring for a child with a
potentially life threatening allergy should be trained
using the specific trainer prescribed and get
comfortable with use
• When developmentally
appropriate children should
practice with trainers as well
Call 911 for Suspected Anaphylaxis
• Caller should state that child having anaphylaxis and request licensed responders
that can administer epinephrine
• It is strongly suggested that the child be taken to the Emergency Department via
Ambulance (child may need additional care or experience a biphasic reaction)
• After epinephrine is administered and after 911 called, then call emergency
contacts as per emergency care plan
• If possible keep the child from rising to an upright position. Consider supine
positioning with legs elevated if comfortable and appropriate, but caution with
vomiting and respiratory distress
(Sampson et al. JACI 2006;117:391-7)
(Pumphrey. JACI. 2003;112:451-2)
(Guidance for Managing Food Allergies in Schools And Licensed Early Care and Ed. Programs. 2012)
Bust Anaphylaxis Myths
Bust Anaphylaxis Myths
Bust Anaphylaxis Myths
Bust Anaphylaxis Myths
Bust Anaphylaxis Myths
Bust Anaphylaxis Myths
Emergency Preparedness Take
Home Points
Know how and when to give
epinephrine
Always have 2 epinephrine doses
available
Call 911 for Anaphylaxis
Food Allergy Management must
be Implemented in all Settings
Home
School
Parties and Play Dates
Restaurants
Alternative Care Givers
Involve an Allergist
• Develop a collaborative relationship with an allergist
comfortable managing pediatric food allergy
• Refer to and involve an allergist early on
(NIAID 6.4.2.5)
• Contact an allergist while waiting for consultation when
needed
Use Resources
NIAID Guidelines for the Diagnosis and
Management of Food
• NIAID collaboration to offer concise guidelines
for healthcare professionals
• Recommendations on
– Diagnosis
– Testing
– Management non-life-threatening allergic
reactions
– Diagnosis and management of food
induced anaphylaxis
•
Offered in full guidelines, summary for
healthcare professionals and summary for
parents and caregivers
http://www.niaid.nih.gov/topics/foodallergy/clinical/Pages/default.aspx
Additional Resources
– Living Confidently Handbook (English and Spanish)
• www.allergyhome.org/handbook
– Label Reading section
• www.allergyhome.org/labels
– Cross-contact section
• www.allergyhome.org/cross-contact
– Free Chapter Champion’s Webinar (AAP/AAN)
“Food Allergy: Epidemiology, Diagnosis and Management in the Medical Home”
https://www.youtube.com/watch?v=vTp5lnexj_Y&feature=youtu.be
Thank You
Slides created by Michael Pistiner MD, MMSc and used for AAP/AAN
Chapter Champion’s Webinar: “Food Allergy: Epidemiology, Diagnosis and
Management in the Medical Home”
https://www.youtube.com/watch?v=vTp5lnexj_Y&feature=youtu.be